Otolaryngology Coding Alert

Even though Medicare has always been impossibly stingy when it comes to reimbursement for intraoperative facial nerve monitoring, knowing whom to bill and how will allow you to fight for all the reimbursement you're entitled to.

Otolaryngologists may provide intraoperative nerve monitoring "to hopefully eliminate the possibility of injury to the facial nerve (cranial VII) during mastoidectomy, parotidectomy and thyroidectomy," says Darlene Reed, CPC, Northland ENT, Liberty, Mo. Intraoperative monitoring is provided with other electro-physiologic studies, such as electroencephalogram (EEG), electromyography (EMG), or nerve conduction studies (NCS), which establish a baseline for comparison during the surgery. 1. Assign the Study First "The time spent performing or interpreting the baseline electrophysiologic study(ies) should not be counted as intraoperative monitoring, but represents separately reportable procedures," CPT states. When reporting intraoperative nerve monitoring, "you must bill the primary procedure first," Reed says. Two codes describe EMG studies provided to the cranial nerve. When the study is conducted unilaterally, as occurs for ear and parotid surgeries, use 95867 (Needle electromyography, cranial nerve supplied muscles, unilateral). When the study is performed bilaterally, e.g., for thyroid surgeries, assign 95868 (Needle electromyo-graphy, cranial nerve supplied muscles, bilateral). 2. Report the Monitoring Second For ongoing intraoperative testing and monitoring during surgical procedures, CPT designates +95920 (Intraoperative neurophysiology testing, per hour [list separately in addition to code for primary procedure]). In the extensive notes following the definition, CPT instructs coders to use code 95920 in conjunction with the code for the study performed, such as 95867 and 95868. "So, if billing EMG or NCS, 95920 must go with it," says Tara R. Kay-Ritter, appeals coordinator, Atlanta ENT, Allergy & Asthma Associates P.C.

"This code is billed per hour, so report this code by the number of appropriate units," Ritter says. "An hour is reached when 30 minutes has passed, so report two units for 90 minutes." 3. Append Modifier -26 The 2002 National Physician Fee Schedule Relative Value File divides 95867, 95868 and 95920 into professional and technical components. This means that modifier -26 (Professional component) applies to both of the study codes as well as the monitoring code, Ritter says.

When an otolaryngologist provides the professional component of the study or the monitoring and does not own the equipment, report the appropriate codes appended with modifier -26. The hospital assigns modifier -TC (Technical component) for the cost of the equipment. If you report the global code, the insurer assumes that the physician provided the professional and technical components. For instance, suppose an otolaryngologist performs a total thyroidectomy. Due to the potential risk of injury to the nerve, the surgeon monitors the nerve for 60 minutes during the surgery, using an EMG to compare the patient's pre-, during and postsurgery [...]